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Successful Interventions 8th October 2008. Presented by John McCollum BAE SYSTEMS Military Air Solutions Head of Aircraft Maintenance & Maintenance Training. Royal Aeronautical Society Human Factors Group, Engineering (HFG:E). Contents. BAE Systems MAS Background

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slide1

Successful Interventions8th October 2008

Presented by

John McCollum

BAE SYSTEMS Military Air Solutions

Head of Aircraft Maintenance & Maintenance Training

Royal Aeronautical Society Human Factors Group, Engineering (HFG:E)

contents
Contents
  • BAE Systems MAS Background
  • Safety Exemplar challenge & where are you?
  • MAS Error Management Programme
  • Our System Challenge!
  • Successful Interventions
  • Our next steps towards a SMS
  • Summary
exemplar challenge
Exemplar Challenge
  • The Leadership of BAE Systems has committed The Company to an “exemplar” position on safety:
  • This means zero tolerance on unsafe workplace and unsafe working practices to be delivered within each business through target driven performance improvements across both leading and lagging indicators.
  • Includes the safety obligation with our Partners and Providers.
  • Safety Culture is defined as an organisations values and behaviours, modelled by its leaders, and internalised by its team members”
  • This means leading by example!
where are you

EXEMPLAR / GENERATIVE

Safety is how we do business round here

ADVANCED / PROACTIVE

We work on problems that we still find

Increasingly Informed

STANDARD / CALCULATIVE

We have systems in place to manage all hazards

Increased Trust and Accountability

FOUNDATION / REACTIVE

Safety is important, we do a lot every time we have an accident

PATHOLOGICAL

Who cares as long as we’re not caught

Based upon SHELL model

Where are you?
where are you6
Where are you?

The Three “ages” of Safety Management

Technology

  • Behaviours
  • Visible Leadership
  • Personal Accountability
  • Shared Attitudes
  • Safety as a profit centre
  • Engineering
  • Equipment design
  • Design standards
  • Regulatory compliance

Systems

Numbers of Incidents

  • Quality Systems
  • Human Factors/CRM
  • Error management systems
  • Competence
  • Risk Assessment

Culture

Time

With permission: Why is HSE so Important? A business approach Prof. Patrick Hudson, Leiden University Modified by Baines & McCollum

8

the mas programme

2004

2005

2006

2007

2008

MEDA Training

Senior Mgt HF Training

HF Programme

EMS Training

Continuation Training

Safety Review Board

Safety Action Groups

SMS Training

The MAS Programme

Reactive “Systems”

Proactive “Culture”

MEMS Report 700 +

MEDA Investigations 200 +

Initial HF Trained 2600 +

our system challenge
Our System Challenge
  • System within a system
  • 1000+ Initial HF trained are RAF and Sub-Con personnel
  • Different cultures & approaches
  • Different maturity of systems
  • Unite under flight safety
  • Sharing & influencing other Organisations approaches
  • MAOS helping the message
  • Partnered approach to policy, training & operation
  • Military forums now forming
slide10

Maintenance Model Example

(Reactive)

(Proactive)

Adapted from Air France / Baines & Simmons / ICAO 9859

slide11

Operational Risk Management in Maintenance

Hazard identification, assessment and control, should be an integral part of routine maintenance, rather than limited to project lifecycle phases and implicit personal action.

Typical Hazard Considerations for Maintenance

Need to consider assessments by aircraft rectification lines and component bays, using personnel from these areas.

the basic bow tie concept

CAUSED BY

RISK

RESULTING IN

The Basic Bow Tie Concept

Events and

Circumstances

Preventive Controls

Recovery Controls

Harm

Defences or

Safety Controls or

Secondary Hazards ?

Threat

HAZARD

CONSEQUENCES

Threat

Top Event

Threat

Undesirable event with

potential for harm or damage

Continuing Airworthiness activities

Maintenance activities

Flight Operations activities

With permission: Baines & Simmons

Modified by McCollum

summary
Summary
  • Successful Interventions can come from investing in HF learning, but you must be prepared for the journey.
  • A successful Error Management System needs :-
      • Energy!
      • Just Culture led from the Top plus Opinion Leaders
      • Comprehensive investigations with loads of feedback / publicity
  • Energy!
  • Feedback the investigations into your training
  • Then the toe in the water
  • Energy!
  • Then the deluge begins
  • A Safety Management System can only start once you have a working HF and Error Management System – all about behaviour
  • The system must integrate within the bigger system!